Be crystal clear when establishing goals and expectations at the very beginning of therapy and be sure to revisit these regularly at subsequent sessions. For the best patient response, you want to be sure you are both working toward the same outcomes. If the patient has an unrealistic goal in mind, be sure to address it early on, just as you would do during an in-person session.
One of the consequences of the pandemic is the dramatic growth of Telehealth and Telemedicine. But how can doctors and providers best care for their patients when they are not physically in front of them? What do doctors wish patients knew in order to make sure they are getting the best results even though they are not actually in the office? How can Telehealth approximate and even improve upon the healthcare that traditional doctors’ visits can provide?
In this interview series, called “Telehealth Best Practices; How To Best Care For Your Patients When They Are Not Physically In Front Of You” we are talking to successful Doctors, Dentists, Psychotherapists, Counselors, and other medical and wellness professionals who share lessons and stories from their experience about the best practices in Telehealth. As a part of this series, I had the pleasure of interviewing Angela Fishman, licensed physical therapist and owner of My Pelvic Therapy, PLLC, a telehealth physical therapy private practice.
Angela received her physical therapy degree from Duke University and has over 30 years of experience as a PT, with 18 of those years specializing in the niche of pelvic floor physical therapy. Her private practice leverages technology to bring therapy directly to patients in their own home, opening up access to this important subspecialty area in which there are relatively few specially-trained PT’s.
Thank you so much for joining us in this interview series! Before we dive in, our readers would love to “get to know you” a bit better. Can you tell us a bit about your ‘backstory’ and how you got started?
Thanks for having me! I first got really interested in treating patients with pelvic floor disorders after having my first baby. Knowing that childbirth is one of the top risk factors for developing incontinence, I fully expected my physician to inquire about this at my 6-week postpartum visit — if not in person, then at least through the questionnaire they asked me to complete prior to my visit. Stunningly, I wasn’t asked any pelvic floor questions at all.
It made me realize that pelvic floor conditions were being undercounted and undertreated, because let’s face it — if the doctors weren’t asking about it, then patients weren’t going to talk about it! I knew well from my PT training that pelvic floor issues were not only very common but also very treatable, and I found it incredibly disappointing that this doctor-patient moment for postpartum women was being wasted. This is what lit the fire under me to pursue a specialization in this field.
Over time, I began to fully appreciate how widespread pelvic floor problems really are in both men and women. At the same time, I became aware of the huge shortage of pelvic floor PT’s, which really impacted access for patients. When I started out in this field, it was not unusual for a patient to have to wait 3–4 weeks to get an appointment for pelvic floor therapy. It was this combination of a large number of patients needing this type of service and a shortage of therapists trained to provide it that spawned my idea in 2019 to start a telehealth physical therapy private practice. (The pandemic was actually just a very strange coincidence!)
Can you share the most interesting story that happened to you since you began your career?
As a physical therapist, I get the privilege of getting to know patients quite well, because I generally see them 1–2 times per week for several weeks. The stories and situations to which I‘ve been exposed run the gamut from entertaining to sad, hysterical to inspirational, and are oftentimes heartwarming. I know you only asked for one, but I hope you’ll allow me to share two stories with you, because each taught me a significant lesson and has impacted how I treat patients to this day.
When I first started treating patients with pelvic floor problems, I was lucky enough to have a mentor. She really helped to show me the ropes, and when she felt I was ready, she offered me the opportunity to co-treat a patient with her for several sessions. We got to know this patient quite well over the course of her therapy, and due to the intimate nature of her pelvic floor problem, we got to know a lot about the troubles she and her husband were having in dealing with the perineal pain she was experiencing following the birth of their first son.
At the conclusion of her final physical therapy session, she thanked us profusely for helping her with her pain, we said our goodbyes, and she went on her way. The next day at work, my mentor and I were called to the front desk of our department to receive a delivery. To our happy surprise, we found waiting for us a huge bouquet of flowers, with a card inscribed to us, “Thank you so much for the therapy! You guys rock.”. While this isn’t an unheard-of gesture, it was a very much appreciated one. But what really got our attention, was the signature: it wasn’t signed by our patient — it was signed by our patient’s husband!
It was a potent reminder of how when we treat a patient, we can have far-reaching effects beyond just the one person, and often positively impact our patients’ relationships as well.
Lesson 1: Appreciate the web of people you are affecting, beyond the patient sitting in front of you.
When I was a PT student and on a clinical rotation at a rural hospital, I was assigned a patient who had an ankle fracture. This patient had fallen down her front porch stairs and suffered a pretty bad break, which required a surgical repair. Because the patient had diabetes, her incisions weren’t healing well, so she was sent to physical therapy for wound care, which is how I had the opportunity to meet her. I treated this patient daily for about 2 weeks and during this time got to know her fairly well — she was a deeply religious, kind, loving soul, and I relished our sessions together.
One day when she was in our department for therapy, the orthopedic surgeon who had operated on her ankle came to see the patient. He asked me to raise her leg out of the therapeutic whirlpool so he could see her ankle, which I promptly did. Without ever addressing or acknowledging the patient directly, the surgeon took one look at her poorly-healing ankle and said “yep, it’s going to have to come off”, meaning he was going to have to amputate. He then turned and walked away, leaving my patient frozen in shock and fear, and me slack at the jaw for the complete lack of compassion I had just witnessed.
Lesson 2: Empathy must come first. A patient is so much more than the sum of her body parts.
Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?
Over the years as a physical therapist, I’ve learned the value of therapeutic touch and the healing power of which it is capable. But what I’ve found to be even more powerful is the value of listening — really deep-down listening. A few years into my career, I read a quote that was (incorrectly) attributed to Maya Angelou: “People may forget what you say, and they may forget what you do, but they will never forget how you made them feel.”
It really resonated with me, because it was exactly what I was experiencing with my patients. It didn’t matter how well I explained a problem, or how technical a manual therapy maneuver I tried — if I wasn’t truly and actively listening and making them feel heard, my therapy sessions would fall flat.
Of course, this wise lesson applies to life outside of work as well!
None of us are able to achieve success without some help along the way. Is there a particular person who you are grateful towards who helped get you to where you are? Can you share a story about that?
I am extremely grateful to a former manager, under whom I worked for many years. She took me under her wing and gave me opportunities to get uncomfortable. In order to help me grow, she frequently pushed me to get in front of residents, physicians, and top hospital administrators to do large and intimidating department presentations, wisely knowing that growth only really happens when we are uncomfortable. And boy, was I uncomfortable! But over time, it got easier and more natural, and it is these skills which helped give me the confidence to leave a traditional PT career and start my own telehealth private practice. I’ll forever be indebted to her for pushing me.
Ok wonderful. Let’s now shift to the main focus of our interview. The pandemic has changed so many things about the way we behave. One of them of course, is how doctors treat their patients. Many doctors have started treating their patients remotely. Telehealth can of course be very different than working with a patient that is in front of you. This provides great opportunity because it allows more people access to medical professionals, but it can also create unique challenges. To begin, can you articulate for our readers a few of the main benefits of having a patient in front of you?
Traditionally, physical therapy is a heavily “hands-on” medical profession, so having a patient right there with you in the office is logically a great way to be able to facilitate healing through the power of touch. Also, because some therapy techniques can at times be uncomfortable, it can be especially helpful to have a patient right in front of you in order to better read their response to a particular technique or exercise. Sometimes what a patient says and what they are feeling can be two different things!
In addition, because of the intimate nature of some pelvic floor problems, being in the same room with a patient during therapy can allow types of treatments to the pelvic floor muscles that just aren’t possible via telehealth.
On the flip side, can you articulate for our readers a few of the main challenges that arise when a patient is not in the same space as the doctor?
When providing telehealth PT, one must be ready for many of the same types of circumstances and problems that can occur with in-person therapy. In addition, telehealth brings its own set of challenges (including bringing new meaning to the “physical” in physical therapy!). Here are several challenges for which one must prepare when providing PT via telehealth:
- How to handle an emergency with the patient if one arises
- Being able to troubleshoot with a patient to handle technology challenges
- Maintaining privacy for the patient, both at the patient’s home, and at the practitioner’s office
- How to obtain the same therapeutic outcomes for your patients as they would receive if seeing you in person
- Recognizing when a patient is not an appropriate fit for telehealth, and needs to be seen in person
- Being able to provide empathy and comfort through the screen
Fantastic. Here is the main question of our interview. Based on your experience, what can one do to address or redress each of those challenges? What are your “5 Things You Need To Know To Best Care For Your Patients When They Are Not Physically In Front Of You ? (Please share a story or example for each.)
(If you’d like to see a video of my answers, please click here.)
Careful planning before taking on Telehealth patients will set you up for your best chances of success in using this powerful modality. Things to keep in mind:
Safety: While “in the safety of your own home” may be a good telehealth motto, it does not mean that you should not be prepared for the unexpected. Have your emergency protocols in place before embarking on telehealth therapy. Have an emergency contact name and number, as well as your patient’s phone number and address readily available so you can take action immediately if the need arises.
Technology: Have a plan in place for when things go wrong during your therapy session (because they will!). What will you do when your patient can’t hear you, or you can’t see their picture, or there is a delay in transmission which is impacting your ability to communicate? I have found it helpful to keep a log of every tech issue I run into, and how we resolved it; the log has helped me become more adept at handling issues as they occur.
It is also a good idea to share a “best practice” list with your patient ahead of time, including suggestions which will increase the chances of a successful telehealth session, such as using WiFi instead of cellular, and ensuring no other family member is streaming videos or playing video games during your session. And be sure to let your patient know exactly what they can expect from you if a tech issue arises, or you get disconnected.
Privacy: It should go without saying that you need a HIPAA-compliant platform for providing telehealth services. In addition, you will want to make sure you are able to keep your treatment area private from other coworkers, or if you are treating from home, from any family members.
Be sure your patient is aware of their responsibility of controlling who is present in their home for their therapy session, so they can maintain the level of privacy that they desire.
Efficacy: Learning to provide effective physical therapy via telehealth takes some practice. For the best chances of helping your patient reach their treatment goals, consider these points:
First, not every patient is an appropriate candidate for telehealth, for a variety of reasons, so if you realize you cannot provide the same level of effective care via telehealth as you would be able to in person, then remember that you are ethically required to treat them in person, or if that is not possible, then to assist your patient in finding another qualified PT to provide in-person care.
Second, to provide the best level of care, it can help to practice your communication skills ahead of time with a friend or family member, or even with yourself via your camera on the screen. Note what you look like as you talk — do you make good eye contact? Do you use too many gestures which may be distracting? Do you talk in an animated fashion, or do you find you speak in a monotone voice? When you look away from the camera, do you explain to the patient what you are doing so they understand why you’ve broken eye contact? Optimizing all these things can help improve the efficacy of your session, and greatly enhance your patient’s satisfaction.
Thirdly, hone your observation and listening skills. Without the patient there in front of you to apply your manual assessment and treatment skills, you will need to depend on laser-sharp listening skills and keen observation to ensure excellence. Reading subtle cues from your patient can help you interpret how she/he is responding to your interventions.
Finally, take concrete steps to minimize your patient’s anxiety at all stages of treatment. Especially with levels of anxiety running so high these days due to the pandemic, anything that you can do to minimize it during your interactions with your patients will greatly assist them in being more successful in therapy. Be clear with them about things such as: how to use your patient portal; how payment and/or insurance works; the best way to contact you if they have questions or problems; how long a typical session lasts; and what they should wear during therapy. Seeing any healthcare practitioner can be stressful, so recognizing this ahead of time and taking steps to alleviate it can really boost your success with your patients.
Consider your communication style during telehealth, as it may need to be adjusted from what you are accustomed to when seeing patients in person. Some tips which I’ve found to be helpful include:
- Be crystal clear when establishing goals and expectations at the very beginning of therapy and be sure to revisit these regularly at subsequent sessions. For the best patient response, you want to be sure you are both working toward the same outcomes. If the patient has an unrealistic goal in mind, be sure to address it early on, just as you would do during an in-person session.
- Follow up every session with written instructions
- Be very clear what your expectations are for your patient after your session is finished; for instance, did you instruct them in a home exercise program? Do you want them to do it every day? Every other day? It is important that your patient have a clear understanding of their role in their healing.
Can you share a few ways that Telehealth can create opportunities or benefits that traditional in-office visits cannot provide? Can you please share a story or give an example?
Telehealth is a fantastic way to remove some of the common barriers to attending PT in person, such as distance to a clinic, the need for a babysitter or other caregiver, taking time off work, accounting for the travel time to and from the clinic, and managing parking. Also, it enables a patient who might not live near a pelvic floor PT easier access to services. And it goes without saying that telehealth is a vital option for access to services during the COVID-19 pandemic.
Telehealth can also help with other barriers, such as dealing with the anxiety that often builds for pelvic floor patients as they wait in the waiting room for the therapist to call their name. This type of therapy, which for patients is often embarrassing, difficult to talk about, and demands a high level of privacy, often feels more comfortable when taking place in the security of one’s own home.
Let’s zoom in a bit. Many tools have been developed to help facilitate Telehealth. In your personal experiences which tools have been most effective in helping to replicate the benefits of being together in the same space?
I have found that there are only a few simple tools required to provide excellent telehealth PT. These include a top-notch (and thankfully reasonably priced) webcam, a professional microphone, and great lighting.
If you could design the perfect Telehealth feature or system to help your patients, what would it be?
I would love a system that would self-correct any tech issues! Beyond that, having the ability to see a patient in 3D would be amazing; I think it would cut down on some of the time it takes to fully evaluate a new patient by making it easier to appreciate how they move through space in three dimensions.
Are there things that you wish patients knew in order to make sure they are getting the best results even though they are not actually in the office?
The only real difference I see from the patient side of things in order to ensure the best results is to work on getting the best tech connection. Otherwise, whether a patient is seen in person or via telehealth, the same things hold true:
- Write out your questions ahead of time
- Follow your home program as prescribed
- Clearly communicate any difficulties that arise due to your home program or any other component of treatment
The technology is rapidly evolving and new tools like VR, AR, and Mixed Reality are being developed to help bring people together in a shared virtual space. Is there any technology coming down the pipeline that excites you?
As I mentioned, being able to see a patient in 3D would be exciting. However, while some patients may respond positively to some of these newer tools, I overall prefer to keep things stripped down and simpler for the vast majority of my patients. Pain and dysfunction can be overwhelming to a person; the last thing you want to do is increase anxiety by adding unnecessary complexity to the technology portion of the visit.
Is there a part of this future vision that concerns you? Can you explain?
Physical therapy is a very human-to-human experience; anything that were to get in the way of that, such as robotics or AI technology would be of potential concern to me.
Ok wonderful. We are nearly done. Here is our last “meaty” question. You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. 🙂
What a great question! A well-functioning pelvic floor is so important for overall health. My dream is two-fold:
- That every person who has a baby is offered an evaluation by a pelvic floor physical therapist
- That every person of every gender is asked about his or her pelvic floor muscle function at the yearly well visit with his/her doctor
How can our readers further follow your work online?
Readers can find me at mypelvictherapy.com. There, they can also sign up for my monthly newsletter where I include up-to-date articles, promotions, exercises, and other tips and tricks to help achieve and maintain a healthy and happy bladder, core, and pelvic floor.
Thank you so much for the time you spent doing this interview. This was very inspirational, and we wish you continued success.
I appreciate the opportunity. Thank you so much for inviting me.